Provider Demographics
NPI:1346088333
Name:KOLLEK, MERCY J
Entity type:Individual
Prefix:
First Name:MERCY
Middle Name:J
Last Name:KOLLEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MERCY
Other - Middle Name:
Other - Last Name:CHACHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135-46 GRAND CENTRAL PARKWAY
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1088
Mailing Address - Country:US
Mailing Address - Phone:347-637-8379
Mailing Address - Fax:
Practice Address - Street 1:750 TILDEN ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6013
Practice Address - Country:US
Practice Address - Phone:347-637-8379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY722289163W00000X
NYF406101363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse